Health inequality monitoring:
with a special focus on low- and
middle-income countries
Lecture 2: Health indicators
and equity stratifiers
Health indicators within the Monitoring,
Evaluation and Review framework
INPUTS AND
PROCESSES
• Health
financing
• Health
workforce
• Infrastructure
• Information
• Governance
OUTPUTS
OUTCOMES
• Service
access and
readiness
• Service
quality and
safety
• Coverage of
interventions
• Risk factors
and
behaviours
IMPACT
• Health status
• Financial risk
protection
• Responsiveness
Source: Adapted from Monitoring, evaluation and review of national health strategies: a country-led platform for information and
accountability. Geneva, World Health Organization, 2011.
2 | Handbook on Health Inequality Monitoring
Selecting a package of health indicators
for monitoring
• The package should represent the entire
continuum of health services and collection of
health outcomes within a topic
• For expansive topics, the package should
cover each component of the WHO’s
Monitoring, Evaluation and Review framework
• For narrowly-defined topics, inputs and
processes indicators may be less relevant
3 | Handbook on Health Inequality Monitoring
Indicators for reproductive, maternal and child
health monitoring
INPUTS AND
PROCESSES
OUTPUTS
•Health financing
•Service access
and readiness
•expenditure per target
population (children,
women, etc.)
•General government
•expenditure on health
as a percentage of
general government
expenditure
•Health workforce
•midwives, per 10 000
population
•Governance
•presence of key
policies to promote
maternal and child
health
•facilities that offer
and meet tracer
criteria for basic
and
comprehensive
obstetric care, per
10 000 pregnant
women
•caesarean section
rate in rural
populations
•facilities that offer
and meet tracer
criteria for child
health services, per
1000 children
•Information
•births registered
•deaths registered (with
cause)
OUTCOMES
•Coverage of interventions
•antenatal care
•births attended by skilled health
personnel
•immunization coverage
•family planning needs satisfied
•children with diarrhoea receiving oral
rehydration therapy
•children with fever receiving antimalarials
•insecticide-treated bednet use
•antiretroviral prophylaxis among HIVpositive pregnant women
•vitamin A supplementation among
children
•postnatal care
IMPACT
•Health status
•under-five mortality
•maternal mortality
ratio
•child mortality by
major cause of
death, by sex and
age
•Financial risk
protection
•out-of-pocket
payments as a
percentage of total
health expenditure
•Risk factors and behaviours
•contraceptive prevalence
•access to safe water
•access to improved sanitation
•low birth weight among newborns
•early initiation of breastfeeding
•children who are stunted or underweight
Source: Adapted from Monitoring, evaluation and review of national health strategies: a country-led platform for information and
accountability. Geneva, World Health Organization, 2011.
4 | Handbook on Health Inequality Monitoring
Tracer and composite indicators
• Tracer indicator: a specified health indicator
chosen to represent a broader health topic
– For example: births attended by skilled health
personnel
• Composite indicator: an index composed of
several indicators within a health topic to
represent that topic
– For example: index of multiple indicators of
maternal care, immunization, treatment of sick
children and family planning
5 | Handbook on Health Inequality Monitoring
Equity stratifiers
• Also called “dimensions of inequality”
• For example: PROGRESS
Place of residence (rural, urban, etc.)
Race or ethnicity
Occupation
Gender
Religion
Education
Socioeconomic status
Social capital or resources
6 | Handbook on Health Inequality Monitoring
Selecting and defining equity stratifiers
• Equity stratifiers should have relevance within the
population
– For example, consider the possible influence of certain
religions on health behaviours
• Relevance may vary depending on the health
measure
– For example, consider which equity stratifiers would be
relevant for traffic accidents versus contraceptive use
• Criteria to define subgroups depends on data
collection, data availability and population
characteristics
7 | Handbook on Health Inequality Monitoring
Direct and proxy measures to define
economic status
• Direct measure: income
– Measures all money received during a specific time (employment, sales,
government transfers, gifts, financial investments, etc.) OR only money
earned from employment
– May be calculated for an individual or per household member
– What about non-monetary income? Transitory or irregular income? Sensitive
topic in poor households?
• Direct measure: consumption and expenditure
– Measures final use of goods and services, and money payments to obtain
them
– Information may be difficult to collect
• Proxy measure: asset index
– Measures asset ownership, housing and/or access to services
– Data are easy to collect
– May construct asset indices using methods such as principal component
analysis
8 | Handbook on Health Inequality Monitoring
Principal component analysis
• PCA is a data reduction method to calculate
household wealth
• Key question: how can several household assets be
aggregated into a single proxy variable of
household wealth?
• Survey questions gather data about assets/service
access  uncorrelated principal components 
weights are assigned to each asset included in the
index  aggregated score is calculated for each
surveyed household
– Based on this aggregate score, households may be
ranked and grouped into quintiles
9 | Handbook on Health Inequality Monitoring
Age as an equity stratifier
• Demographic data, such as age, are routinely
collected by data sources
• Age is a relevant equity stratifier only if health
differences are due to unfair or unjust access
to health services on the basis of age (i.e. age
discrimination)
– For example, age-disaggregated analyses of
contraceptive prevalence may reveal differences
between adolescent and adult women
10 | Handbook on Health Inequality Monitoring
Health inequality
monitoring: with a
special focus on
low- and middleincome countries
Full text available online:
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32_eng.pdf